Critical Care Medicine: Next Target for Contracting "Without physician gatekeepers, managed care cannot work, because neither plan administrators, case managers, nurses, hospital executives, stockholders, patients, nor their relatives can write orders for patient care." CQ - April, 1995 The Intensive Care Unit has remained isolated from managed care scrutiny because of its inherent technological and clinical complexity. It has been much easier to focus managed care on clinical areas that are relatively straightforward and involve less potential for poor outcomes. The next wave of management will undoubtedly begin to center on the high-complexity, high-risk, resource and labor intensive areas of medicine. The ICU, more than any other cost center, is a logical target for implementing a new practice model. Before discussing how one would go about contracting for critical care services, it is important to have a clear understanding of the traditional way in which critical care is practiced in the US, a way which is notoriously prone to waste and mismanagement when compared to other countries. This figure demonstrates the current "business as usual" approach to critical care in the United States. A patient is admitted to the ICU, often for reasons that are poorly explained. Studies have shown that up to 40 percent of ICU patients are in the ICU in order to receive "better monitoring" (1). The traditional ICU patient is then managed by a team approach which basically consists of a subspecialist consultant for any organ system that demonstrates abnormal function. This "team" is "led" by the patient's attending physician who is usually not required to have formal training in Critical Care, Pulmonary, or Cardiology. Unfortunately, the "team" rarely "gets on the field" at the same time and when the patient begins to deteriorate, nurses, family, and the patient often have a difficult time identifying which physician is really in charge. This model for patient care in the ICU evolved out of a combination of three forces: (1) The specialization of medical practice, in which knowledge of science and medicine has expanded, allowing curriculums to develop for the training of clinicians in highly refined specialty areas, (2) Fee-for-service reimbursement which sustains the team approach by providing compensation to consultants and attendings, regardless of their actual contribution to the case, and (3) The perception that malpractice risk is lessened by getting more specialists involved in the case. The team approach to critical care does not exist in all ICUs. It mainly affects adult medical ICUs and surgical ICUs. Many smaller hospitals have only one ICU which provides a mixture of cardiac, medical, and surgical critical care. CCUs tend to be run only by cardiologists as long as the patient has single organ problems, and some surgical ICUs are run by either surgical Intensivists or by anesthesiologists with Critical Care training. However, the fact is that less than half of all ICUs in the United States have directors who are certified in Critical Care and only 6 percent provide 24-hour in-house attending physician coverage! (5) Neonatology and pediatric critical care have definitely evolved into a different practice model. Neonatologists, who essentially manage one disease and its complications, and pediatric Intensivists have clear leadership roles in their ICUs. Although similar financial and legal considerations are at play in pediatrics, general pediatricians have not tried to maintain the attending physician role when their patient develops a critical illness. This is probably because of the profound emotional stress involved in dealing with sever morbidity and mortality in this age group and because of the technical challenges associated with performing invasive procedures in children. Provocative data concerning the difference in outcomes between ICUs in Australia and the United States has recently been published. (6) Australian ICUs in New South Wales showed improved survival and a smaller range of outcomes than ICUs in the United States. The improved mortality rates were more notable at higher APACHE II scores despite similarities in patient demographics, reasons for admission, available technology, and interventions. A key difference in the practice of Critical Care between the two countries is the clear leadership role played by Intensivists in Australia. A simple fact makes it possible and desirable to replace this traditional model of ICU care with a model that lends itself much more readily to manage care, cost control, and to the preservation and advancement of high quality outcomes. Managed care has made huge advances by empowering primary care physicians as gatekeepers and allowing them to be recipients of the lion's share of capitated payments. Without physician gatekeepers, managed care cannot work, because neither plan administrators, case manager, nurses, hospital executives, stockholders, patients, or their relatives can write orders for patient care! A gatekeeper does exist for the system's sickest and most expensive patients. That gatekeeper is know as an Intensivist or Critical Care Specialist. A new model for Critical Care, empowering the Intensivist as a gatekeeper in the same way that primary care physicians have been empowered for lower acuity illnesses, must evolve in order to allow for further cost reductions and to standardize the quality of ICU care. - by Bruce Gipe, MD |
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